Free - - Mississippi

F0064 - Page 1 of 1

OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633

Application for Certificate of Withdrawal of a Foreign Business Trust
1. Name of Foreign Business Trust

2. Its state or country of organization is

3. The foreign business trust is not transacting business in Mississippi and hereby surrenders its authority to transact business in Mississippi 4. The foreign business trust revokes the authority of its registered agent in Mississippi to accept service on its behalf and appoints the Secretary of State as its agent for service of process in any proceeding based upon any cause of action arising during the time it was authorized to transact business in the State of Mississippi 5. The post office address to which the Secretary of State may mail a copy of any process against the business trust that may be served on him/her is; P. O. Box

City, State, Zip4, Zip5

-

6. The Business trust hereby makes a commitment to notify the Secretary of State in the future of any changes in the mailing address given above. Signature

Printed Name

Title

Rev. 07/98